Male genital self-mutilation.

Psychiatric case reports of male genital self-mutilation (GSM) in the literature are rare and mostly anecdotal. Most of them are connected with personality disorders (Goldfield and Glick, 1970; Wise et al., 1989). In men, psychosis is an important cause for GSM, causing up to 80% of automutilations.

INTRODUCTION

From the beginning of the century to this day, 57 cases of male genital self-mutilation (GSM) have been reported in the English literature. In German publications, we found only five case descriptions. Although no precise data are available on the prevalence of male GSM, such acts are presumably much more frequent than the small number of published cases would suggest. In the literature, several features are regarded as risk factors for self-mutilation, such as homosexual or transsexual tendencies, repudiation of the male genitals, absence of a competent male for identification during childhood, feeling of guilt for sexual offences, and self-injury. We report a patient with personality disorder who had injured his external genitals.

CASE REPORT

A 35-year-old man was referred to the outpatient department, with self-inflicted penile incised wound caused with razor blade 1 month back. The patient acknowledged frequent altercations and verbal abuse by the owner of the company.

His marriage produced no children, and he described his marital relationship as amicable and sexually gratifying. His mental status examination was significant for his masculine appearance, gregariousness, and lack of distress. He was interpersonally engaging and eager to please. There were no signs of thought-process disorganization, internal preoccupation, or delusional focus in his presentation material. He was cognitively intact and exhibited a normal range of emotions. He credibly denied suicidal inclination. His review of symptoms showed absence of gender-identity disorder features.

There was no past or family history of any psychiatric illness, chronic medical illness or drug misuse.

The physical examination revealed an average built patient (weight 43.5 kg, height 158 cm) and an older superficial laceration (2×5 cm) at the right prepuce with circumferential incised wound over root of glans. Psychological testing corroborated the absence of psychosis and the likelihood of a primary severe personality disorder.

Dialectical behavior therapy (DBT) was given to the patient to teach the patient skills to cope with stress, regulate emotions and improve relationships with others.

DISCUSSION

About 110 cases of GSM in men have been described in the literature (Greilsheimer and Groves,[1] Martin and Gattaz, and Nakaya[2] Aboseif et al.,[3] Becker and Hartmann,[4]). In the earlier publications, the majority of these patients were either psychotic or intoxicated during automutilation (Greilsheimer and Groves[1]). In recent articles, the number of psychotic patients has been reported to be smaller (Becker and Hartmann[4]).

The authors discuss that this might be due to a double bias as psychiatrists are more frequently involved when the patients are psychotic and these cases tend to be published more frequently.

Psychotic patients with delusions (often religious), sexual conflict associated with guilt, past suicide attempts or other self-destructive behavior and depression, severe childhood deprivation, and major premorbid personality disorder are the group at risk for genital self-amputation. It has been proposed that the eponym, the “Klingsor” syndrome, be applied only to acts of genital self-mutation involving religious delusions.

A review showed that guilt feelings associated with sexual conflicts were the most important factors in the act of psychotic self-mutilation and were also related to religious psychotic experiences that were often the direct motives for the act. Self-mutilators with sexual guilt feelings were likely to mutilate themselves more severely than those without (Nakaya[2]). Even excluding the transsexuals, disturbance of sexual identity was most participating in the act of nonpsychotic self-mutilators. In addition to these, previous history of self-injury took part in the act independently. Male genital self-mutilation is exceedingly rare in psychiatric practice, even if it is not as uncommon as the paucity of published literature on the subject would suggest.[56]

Men who intentionally mutilate or remove their own genitals are likely to be psychotic at the time of the act, to have a number of goals and aims relating to conflicts about the male role, and to be vulnerable to sociocultural and psychological forces in a causal network as yet unknown.

However, from a review of the cases of 53 male self-mutilators, it appears that a significant number involves individuals not psychotic at the time of the act but rather having character disorders and rageful feelings toward themselves or women, and transsexual males who premeditate their own gender conversion surgery.

Suyemoto and MacDonald[7] reported the incidence of self-mutilation in adolescents and young adults between the ages of 15 and 35 to be an estimated 1800 individuals out of 100,000. Self-mutilation has been most commonly seen as a diagnostic indicator for Borderline Personality Disorder. Self-mutilating behavior has been studied in a variety of racial, chronological, ethnic, gender, and socioeconomic populations. People who participate in self-injurious behavior are usually likeable, intelligent, and functional. At times of high stress, these individuals often report an inability to think, the presence of inexpressible rage, and a sense of powerlessness. An additional characteristic identified by researchers and therapists is the inability to verbally express feelings.

In our patient, this aggressive component seems to have been directed against himself, which can mainly be explained by his low self-esteem and insecure personality structure.